Liver Cancer

Staging

Once your diagnosis is made, a process called staging is used to describe the extent of cancer within your body and how far it may have progressed from where it began. Staging helps your doctor select the most effective treatment option for you and assists with determining a prognosis (outlook). To assign a stage, your doctor will evaluate your pathology report, including the results of your tissue biopsy, imaging studies, diagnostic tests and physical exams.

How your liver cancer is staged can be complex and may be confusing, so it is important to be educated about the disease. Ask your doctor or nurse to explain anything that is unclear to you. This knowledge will allow you to take an active role in your treatment plan, and you will feel better prepared to make decisions as you and your doctor plan and manage your overall care.

Understanding the Staging Systems

The two staging systems most commonly used for HCC are the Barcelona Clinic Liver Cancer (BCLC) system and the American Joint Committee on Cancer (AJCC) staging system. Some doctors may use a different system so it is important to make sure you understand the system your doctor uses.

The most commonly used staging system is the BCLC. It is based on three main factors:

1. Tumor characteristics, including the size of the tumor(s), how many tumors are present and whether the tumor(s) causes symptoms.

2. The Eastern Cooperative Oncology Group (ECOG) Performance Status measures how the disease is affecting your ability to do daily activities. It is also a tool used to determine whether the cancer is progressing, potential treatment options and prognosis (outlook). It allows the doctor to better understand how you might tolerate treatment.

3. The Child-Pugh score is used to evaluate liver function. This classification system uses five factors to determine the type of treatment that may be required. The measures are combined into a scoring system that provides doctors with information on how well the liver is working:

  • Albumin is a protein made by the liver.
  • Bilirubin is a part of bile, which is made in the liver.
  • Prothrombin time is how quickly the blood clots. It is sometimes reported as International Normalized Ratio (INR). 
  • Ascites is an accumulation of fluid in the abdomen.
  • Encephalopathy indicates whether liver disease is affecting brain function.

Each of these factors is scored into a point system, which tallies the number of points to assign one of three classes: 

  • Class A: a well-functioning liver
  • Class B: liver function is significantly compromised
  • Class C: severe liver damage

Your doctor will determine the overall stage of the cancer by combining the results from the three factors, which include the tumor characteristics, the ECOG Performance Status and the Child-Pugh score.

The BCLC system may be classified into one of five stages from Stage 0 through Stage D. Following are more details about each BCLC stage.

Stage 0 (very early stage): The tumor is less than 2 cm. The ECOG Performance Status is 0, meaning you are as active as before diagnosis. The Child-Pugh score is A, meaning the liver is working normally.

Stage A (early stage): There may be one lesion that is more than 2 cm, or there are up to three lesions that measure less than 3 cm. The ECOG Performance Status is 0, meaning you are as active as before diagnosis. The Child-Pugh score is A to C, meaning the liver may be working normally, may have mild to moderate damage or may have severe damage.

Stage B (intermediate stage): There may be more than one lesion with at least one that is more than 3 cm, or there are more than three lesions regardless of their size. The ECOG Performance Status is 0, meaning you are as active as before diagnosis. The Child-Pugh score is A to C, meaning the liver may be working normally, may have mild to moderate damage or may have severe damage.

Stage C (advanced stage): The cancer has invaded nearby blood vessels and/or has spread to lymph nodes and/or has spread to other parts of the body. The ECOG Performance Status is 1 to 2, meaning you may not be able to do heavy physical work but can do anything else, or you may be up about half the day and are unable to do any work activities. The Child-Pugh score is A to C, meaning the liver may be working normally, may have mild to moderate damage or may have severe damage.

Stage D (end-stage disease): The tumor may have grown into large blood vessels or spread to other parts of the body, and liver damage is severe. The ECOG Performance Score is 3 or 4, meaning you may be in bed or in a chair for more than half the day and you need help looking after yourself, or you are in bed or in a chair all the time and need complete care. The Child-Pugh score is C, meaning there is severe liver damage.


In addition, doctors may classify liver cancer based on whether it can be entirely resected (surgically removed) and may be described as the following.


  • Localized resectable (confined to the liver and able to be surgically removed)
  • Localized unresectable (confined to the liver but cannot be surgically removed)
  • Advanced (has spread beyond the liver and likely cannot be treated with surgery)

Another staging system that may be used is the TNM system developed by the American Joint Committee on Cancer (AJCC).

The TNM staging system classifies the cancer by tumor (T), node (N) and metastasis (M). The T category describes the size and location of the primary tumor. The N category indicates whether the lymph nodes show evidence of cancer cells. The number and location of these lymph nodes are important because they show how far the disease has spread. The M category describes metastasis (spread of cancer to another part of the body), if any.

A combination of T, N and M is used to assign an overall stage to the cancer. Liver cancers may be Stage I through Stage IV. Stages I, II and III are generally confined to the local area where the cancer is found. Stage IV has likely spread to lymph nodes and other systems in the body. Stage IV is further divided into Stages IVA and IVB.